4.1.1 Monotherapy and Combination Therapy
Zytero is indicated as an adjunct to diet and exercise to improve glycemic control in
adults ( ≥ 18 years) with type 2 diabetes mellitus in multiple clinical settings.
4.1.2 Limitation of Use
Zytero should not be used in patients with type 1 diabetes mellitus or for the treatment
of diabetic ketoacidosis, as it would not be effective in these settings.

Posology
For the different dose regimens, Zytero is available in strengths of 25 mg, 12.5 mg and 6.25 mg film-coated tablets.
Recommended Dosing
The recommended dose of Zytero for adults ( ≥ 18 years) is 25 mg once daily. Zytero may be taken with or without food.
Special population:
Patients with Renal Impairment
No dose adjustment of Zytero is necessary for patients with mild renal impairment
(creatinine clearance [CrCl] ≥60 mL/min).
The dose of Zytero is 12.5 mg once daily for patients with moderate renal impairment
(CrCl ≥30 to <60 mL/min).

The dose of Zytero is 6.25 mg once daily for patients with severe renal impairment
(CrCl ≥15 to <30 mL/min) or with end-stage renal disease (ESRD) (CrCl <15 mL/min or requiring hemodialysis). Zytero may be administered without regard to the timing of dialysis. Zytero has not been studied in patients undergoing peritoneal dialysis.
Because there is a need for dose adjustment based upon renal function, assessment of renal function is recommended prior to initiation of Zytero therapy and periodically thereafter.
Elderly Patients (≥ 65 years old)
No dose adjustment is necessary based on age. However, dosing of alogliptin should be conservative in patients with advanced age due to the potential for decreased renal function in this population.
Patients with Hepatic impairment
No dose adjustment is necessary for patients with mild to moderate hepatic impairment (Child-Pugh scores of 5 to 9). Alogliptin has not been studied in patients with severe hepatic impairment
(Child-Pugh score > 9) and is, therefore, not recommended for use in such patients (see sections 4.4 and 5.2).
Paediatric population
The safety and efficacy of Zytero in children and adolescents < 18 years old have not been established. No data are available.
Method of administration
Oral use.
Zytero should be taken once daily with or without food. The tablets should be swallowed whole with water.
If a dose is missed, it should be taken as soon as the patient remembers. A double dose should not be taken on the same day.

General
Zytero should not be used in patients with type 1 diabetes mellitus or for the treatment of diabetic ketoacidosis. Zytero is not a substitute for insulin in insulin-requiring patients.
Use with other antihyperglycaemic medicinal products and hypoglycaemia
Due to the increased risk of hypoglycaemia in combination with a sulphonylurea, insulin or combination therapy with thiazolidinedione plus metformin, a lower dose of these medications may be considered to reduce the risk of hypoglycaemia when these medicinal products are used in
combination with alogliptin (see section 4.2).
Combinations not studied
Alogliptin has not been studied in combination with sodium glucose cotransporter 2 (SGLT-2) inhibitors or glucagon like peptide 1 (GLP-1) analogues nor formally as triple therapy with metformin and a sulphonylurea.

Renal impairment
As there is a need for dose adjustment in patients with moderate or severe renal impairment, or
end-stage renal disease requiring dialysis, appropriate assessment of renal function is recommended prior to initiation of alogliptin therapy and periodically thereafter (see section 4.2).
Experience in patients requiring renal dialysis is limited. Alogliptin has not been studied in patients undergoing peritoneal dialysis (see sections 4.2 and 5.2).
Hepatic impairment
Alogliptin has not been studied in patients with severe hepatic impairment (Child-Pugh score > 9) and is, therefore, not recommended for use in such patients (see sections 4.2 and 5.2).
Heart Failure
In the EXAMINE trial which enrolled patients with type 2 diabetes and recent acute coronary syndrome, 106 (3.9%) of patients treated with Zytero and 89 (3.3%) of patients treated with placebo were hospitalized for congestive heart failure.
Consider the risks and benefits of Zytero prior to initiating treatment in patients at risk for heart failure, such as those with a prior history of heart failure and a history of renal impairment, and observe these patients for signs and symptoms of heart failure during therapy. Patients should be advised of the characteristic symptoms of heart failure and should be instructed to immediately report such symptoms. If heart failure develops, evaluate and manage according to current standards of care and consider discontinuation of Zytero.

Hypersensitivity reactions
Hypersensitivity reactions, including anaphylactic reactions, angioedema and exfoliative skin conditions including Stevens-Johnson syndrome and erythema multiforme have been observed for DPP-4 inhibitors and have been spontaneously reported for alogliptin in the post-marketing setting. In clinical studies of alogliptin, anaphylactic reactions were reported with a low incidence.
Acute pancreatitis
Use of DPP-4 inhibitors has been associated with a risk of developing acute pancreatitis. In a pooled analysis of the data from 13 studies, the overall rates of pancreatitis reports in patients treated with
25 mg alogliptin, 12.5 mg alogliptin, active control or placebo were 2, 1, 1 or 0 events per
1,000 patient years, respectively. In the cardiovascular outcomes study the rates of pancreatitis reports in patients treated with alogliptin or placebo were 3 or 2 events per 1,000 patient years, respectively.
There have been spontaneously reported adverse reactions of acute pancreatitis in the post-marketing
setting. Patients should be informed of the characteristic symptom of acute pancreatitis: persistent, severe abdominal pain, which may radiate to the back. If pancreatitis is suspected, Zytero should be
discontinued; if acute pancreatitis is confirmed, Zytero should not be restarted. Caution should be
exercised in patients with a history of pancreatitis.
Hepatic effects
Postmarketing reports of hepatic dysfunction including hepatic failure have been received. A causal relationship has not been established. Patients should be observed closely for possible liver abnormalities. Obtain liver function tests promptly in patients with symptoms suggestive of liver injury. If an abnormality is found and an alternative etiology is not established, consider discontinuation of alogliptin treatment.

Macrovascular Outcomes
There have been no clinical studies establishing conclusive evidence of macrovascular risk reduction with Zytero .

Effects of other medicinal products on alogliptin
Alogliptin is primarily excreted unchanged in the urine and metabolism by the cytochrome (CYP) P450 enzyme system is negligible (see section 5.2). Interactions with CYP inhibitors are thus not expected and have not been shown.
Results from clinical interaction studies also demonstrate that there are no clinically relevant effects of gemfibrozil (a CYP2C8/9 inhibitor), fluconazole (a CYP2C9 inhibitor), ketoconazole (a CYP3A4 inhibitor), cyclosporine (a p-glycoprotein inhibitor), voglibose (an alpha-glucosidase inhibitor), digoxin, metformin, cimetidine, pioglitazone or atorvastatin on the pharmacokinetics of alogliptin.
Effects of alogliptin on other medicinal products
In vitro studies suggest that alogliptin does not inhibit nor induce CYP 450 isoforms at concentrations achieved with the recommended dose of 25 mg alogliptin (see section 5.2). Interaction with substrates of CYP 450 isoforms are thus not expected and have not been shown. In studies in vitro, alogliptin
was found to be neither a substrate nor an inhibitor of key transporters associated with drug disposition in the kidney: organic anion transporter-1, organic anion transporter-3 or organic cationic transporter-2
(OCT2). Furthermore, clinical data do not suggest interaction with p-glycoprotein inhibitors or substrates.
In clinical studies, alogliptin had no clinically relevant effect on the pharmacokinetics of caffeine, (R)-warfarin, pioglitazone, glyburide, tolbutamide, (S)-warfarin, dextromethorphan, atorvastatin, midazolam, an oral contraceptive (norethindrone and ethinyl oestradiol), digoxin, fexofenadine, metformin, or cimetidine, thus providing in vivo evidence of a low propensity to cause interaction with substrates of CYP1A2, CYP3A4, CYP2D6, CYP2C9, p-glycoprotein, and OCT2.

In healthy subjects, alogliptin had no effect on prothrombin time or International Normalised Ratio
(INR) when administered concomitantly with warfarin. Combination with other anti-diabetic medicinal products
Results from studies with metformin, pioglitazone (thiazolidinedione), voglibose (alpha-glucosidase inhibitor) and glyburide (sulphonylurea) have shown no clinically relevant pharmacokinetic interactions.

Pregnancy
Pregnancy Category B
There are no data from the use of alogliptin in pregnant women. Animal studies do not indicate direct or indirect harmful effects with respect to reproductive toxicity (see section 5.3). As a precautionary measure, it is preferable to avoid the use of alogliptin during pregnancy.
Breast-feeding
It is unknown whether alogliptin is excreted in human milk. Animal studies have shown excretion of alogliptin in milk (see section 5.3). A risk to the suckling child cannot be excluded.
A decision on whether to discontinue breast-feeding or to discontinue alogliptin therapy should be made taking into account the benefit of breast-feeding for the child and the benefit of alogliptin therapy for the woman.

Fertility
The effect of alogliptin on fertility in humans has not been studied. No adverse effects on fertility were observed in animal studies (see section 5.3).

Zytero has no or negligible influence on the ability to drive and use machines. However patients should be alerted to the risk of hypoglycaemia especially when combined with a sulphonylurea, insulin or combination therapy with thiazolidinedione plus metformin.

Summary of the safety profile
The information provided is based on a total of 9,405 patients with type 2 diabetes mellitus, including
3,750 patients treated with 25 mg alogliptin and 2,476 patients treated with 12.5 mg alogliptin, who participated in one phase 2 or 12 phase 3 double-blind, placebo- or active-controlled clinical studies.
In addition, a cardiovascular outcomes study with 5,380 patients with type 2 diabetes mellitus and a recent acute coronary syndrome event was conducted with 2,701 randomised to alogliptin and 2,679
randomised to placebo. These studies evaluated the effects of alogliptin on glycaemic control and its safety as monotherapy, as initial combination therapy with metformin or a thiazolidinedione, and as add-on therapy to metformin, or a sulphonylurea, or a thiazolidinedione (with or without metformin or
a sulphonylurea), or insulin (with or without metformin).
In a pooled analysis of the data from 13 studies, the overall incidences of adverse events, serious adverse events and adverse events resulting in discontinuation of therapy were comparable in patients treated with 25 mg alogliptin, 12.5 mg alogliptin, active control or placebo.
The most common adverse reaction in patients treated with 25 mg alogliptin was headache.
The safety of alogliptin between the elderly (≥ 65 years old) and non-elderly (< 65 years old) was similar.

Tabulated list of adverse reactions
The adverse reactions are listed by system organ class and frequency. Frequencies are defined as very common (≥1/10); common (≥1/100 to <1/10); uncommon (≥1/1,000 to <1/100); rare (≥1/10,000 to
<1/1,000); very rare (<1/10,000); not known (cannot be estimated from available data).
In the pooled pivotal phase 3 controlled clinical trials of alogliptin as monotherapy and as add-on combination therapy involving 5,659 patients, the observed adverse reactions are listed below (Table 1).

Common:

Infections and infestations
Upper respiratory tract infections
Nasopharyngitis

Nervous system disorders
Headache

Gastrointestinal disorders
Abdominal pain
Gastroesophageal reflux disease

Skin and subcutaneous tissue disorders
Pruritus
Rash

Post-marketing experience:

Immune system disorders
Hypersensitivity

Gastrointestinal disorders
Acute pancreatitis

Hepatobiliary disorders
Hepatic dysfunction including hepatic failure

Skin and subcutaneous tissue disorders
Exfoliative skin conditions including
Stevens-Johnson syndrome
Erythema multiforme
Angioedema
Urticaria

Reporting of suspected adverse reactions
Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the National Pharmacovigilance and Drug Safety Centre (NPC) listed below:
To report any side effect(s):
• Saudi Arabia:
The National Pharmacovigilance and Drug Safety Centre (NPC) Fax: +966-11-205-7662
Call NPC at +966-11-2038222
Exts: 2317-2356-2353-2354-2334-2340. Toll free phone: 8002490000
E-mail: npc.drug@sfda.gov.sa
Website: www.sfda.gov.sa/npc

The highest doses of alogliptin administered in clinical trials were single doses of 800 mg to healthy subjects and doses of 400 mg once daily for 14 days to patients with type 2 diabetes mellitus (equivalent to 32 times and 16 times the recommended daily dose of 25 mg alogliptin, respectively).
Management
In the event of an overdose, appropriate supportive measures should be employed as dictated by the patient’s clinical status.
Minimal quantities of alogliptin are removed by haemodialysis (approximately 7% of the substance was removed during a 3-hour haemodialysis session). Therefore, haemodialysis is of little clinical benefit in overdose. It is not known if alogliptin is removed by peritoneal dialysis.

Pharmacotherapeutic group: Drugs used in diabetes; dipeptidyl peptidase 4 (DPP-4) inhibitors. ATC code: A10BH04.
Mechanism of action and pharmacodynamic effects
Alogliptin is a potent and highly selective inhibitor of DPP-4, >10,000-fold more selective for DPP-4 than other related enzymes including DPP-8 and DPP-9. DPP-4 is the principal enzyme involved in the rapid degradation of the incretin hormones, glucagon-like peptide-1 (GLP-1) and GIP
(glucose-dependent insulinotropic polypeptide), which are released by the intestine and levels are increased in response to a meal. GLP-1 and GIP increases insulin biosynthesis and secretion from
pancreatic beta cells, while GLP-1 also inhibits glucagon secretion and hepatic glucose production. Alogliptin therefore improves glycaemic control via a glucose-dependent mechanism, whereby insulin
release is enhanced and glucagon levels are suppressed when glucose levels are high.
Clinical efficacy
Alogliptin has been studied as monotherapy, as initial combination therapy with metformin or a thiazolidinedione, and as add-on therapy to metformin, or a sulphonylurea, or a thiazolidinedione (with or without metformin or a sulphonylurea), or insulin (with or without metformin).

Administration of 25 mg alogliptin to patients with type 2 diabetes mellitus produced peak inhibition of DPP-4 within 1 to 2 hours and exceeded 93% both after a single 25 mg dose and after 14 days of once-daily dosing. Inhibition of DPP-4 remained above 81% at 24 hours after 14 days of dosing. When the 4-hour postprandial glucose concentrations were averaged across breakfast, lunch and dinner, 14 days of treatment with 25 mg alogliptin resulted in a mean placebo-corrected reduction from baseline of -35.2 mg/dL.

Both 25 mg alogliptin alone and in combination with 30 mg pioglitazone demonstrated significant decreases in postprandial glucose and postprandial glucagon whilst significantly increasing postprandial active GLP-1 levels at Week 16 compared to placebo (p<0.05). In addition, 25 mg alogliptin alone and in combination with 30 mg pioglitazone produced statistically significant (p<0.001) reductions in total triglycerides at Week 16 as measured by postprandial incremental AUC(0-8) change from baseline compared to placebo.
A total of 14,779 patients with type 2 diabetes mellitus, including 6,448 patients treated with 25 mg alogliptin and 2,476 patients treated with 12.5 mg alogliptin, participated in one phase 2 or 13 phase 3 (including the cardiovascular outcomes study) double-blind, placebo- or active-controlled clinical studies conducted to evaluate the effects of alogliptin on glycaemic control and its safety. In these studies, 2,257 alogliptin-treated patients were ≥ 65 years old and 386 alogliptin-treated patients were
≥ 75 years old. The studies included 5,744 patients with mild renal impairment, 1,290 patients with moderate renal impairment and 82 patients with severe renal impairment / end-stage renal disease
treated with alogliptin.
Overall, treatment with the recommended daily dose of 25 mg alogliptin improved glycaemic control when given as monotherapy and as initial or add-on combination therapy. This was determined by clinically relevant and statistically significant reductions in glycosylated haemoglobin (HbA1c) and fasting plasma glucose compared to control from baseline to study endpoint. Reductions in HbA1c were similar across different subgroups including renal impairment, age, gender and body mass index, while differences between races (e.g. White and non-White) were small. Clinically meaningful reductions in HbA1c compared to control were also observed with 25 mg alogliptin regardless of baseline background treatment. Higher baseline HbA1c was associated with a greater reduction in HbA1c. Generally, the effects of alogliptin on body weight and lipids were neutral.

Alogliptin as monotherapy
Treatment with 25 mg alogliptin once daily resulted in statistically significant improvements from baseline in HbA1c and fasting plasma glucose compared to placebo-control at Week 26 (Table 3).
Alogliptin as add-on therapy to metformin
The addition of 25 mg alogliptin once daily to metformin hydrochloride therapy (mean
dose = 1,847 mg) resulted in statistically significant improvements from baseline in HbA1c and fasting plasma glucose at Week 26 when compared to the addition of placebo (Table 3). Significantly more patients receiving 25 mg alogliptin (44.4%) achieved target HbA1c levels of ≤ 7.0% compared to those receiving placebo (18.3%) at Week 26 (p<0.001).
The addition of 25 mg alogliptin once daily to metformin hydrochloride therapy (mean
dose = 1,835 mg) resulted in improvements from baseline in HbA1c at Week 52 and Week 104. At Week 52, the HbA1c reduction by 25 mg alogliptin plus metformin (-0.76%, Table 4) was similar to that produced by glipizide (mean dose = 5.2 mg) plus metformin hydrochloride therapy (mean
dose = 1,824 mg, -0.73%). At Week 104, the HbA1c reduction by 25 mg alogliptin plus metformin
(-0.72%, Table 4) was greater than that produced by glipizide plus metformin (-0.59%). Mean change from baseline in fasting plasma glucose at Week 52 for 25 mg alogliptin and metformin was significantly greater than that for glipizide and metformin (p<0.001). By Week 104, mean change
from baseline in fasting plasma glucose for 25 mg alogliptin and metformin was -3.2 mg/dL compared with 5.4 mg/dL for glipizide and metformin. More patients receiving 25 mg alogliptin and metformin
(48.5%) achieved target HbA1c levels of ≤ 7.0% compared to those receiving glipizide and metformin
(42.8%) (p=0.004).

Alogliptin as add-on therapy to a sulphonylurea
The addition of 25 mg alogliptin once daily to glyburide therapy (mean dose = 12.2 mg) resulted in statistically significant improvements from baseline in HbA1c at Week 26 when compared to the
addition of placebo (Table 3). Mean change from baseline in fasting plasma glucose at Week 26 for
25 mg alogliptin showed a reduction of 8.4 mg/dL compared to an increase of 2.2 mg/dL with placebo. Significantly more patients receiving 25 mg alogliptin (34.8%) achieved target HbA1c levels of
≤ 7.0% compared to those receiving placebo (18.2%) at Week 26 (p=0.002).
Alogliptin as add-on therapy to a thiazolidinedione
The addition of 25 mg alogliptin once daily to pioglitazone therapy (mean dose = 35.0 mg, with or without metformin or a sulphonylurea) resulted in statistically significant improvements from baseline
in HbA1c and fasting plasma glucose at Week 26 when compared to the addition of placebo (Table 3).
Clinically meaningful reductions in HbA1c compared to placebo were also observed with 25 mg alogliptin regardless of whether patients were receiving concomitant metformin or sulphonylurea therapy. Significantly more patients receiving 25 mg alogliptin (49.2%) achieved target HbA1c levels of ≤ 7.0% compared to those receiving placebo (34.0%) at Week 26 (p=0.004).
Alogliptin as add-on therapy to a thiazolidinedione with metformin
The addition of 25 mg alogliptin once daily to 30 mg pioglitazone and metformin hydrochloride therapy (mean dose = 1,867.9 mg) resulted in improvements from baseline in HbA1c at Week 52 that
were both non-inferior and statistically superior to those produced by 45 mg pioglitazone and metformin hydrochloride therapy (mean dose = 1,847.6 mg, Table 4). The significant reductions in
HbA1c observed with 25 mg alogliptin plus 30 mg pioglitazone and metformin were consistent over the entire 52-week treatment period compared to 45 mg pioglitazone and metformin (p<0.001 at all time points). In addition, mean change from baseline in fasting plasma glucose at Week 52 for 25 mg
alogliptin plus 30 mg pioglitazone and metformin was significantly greater than that for 45 mg pioglitazone and metformin (p<0.001). Significantly more patients receiving 25 mg alogliptin plus 30 mg pioglitazone and metformin (33.2%) achieved target HbA1c levels of ≤ 7.0% compared to those receiving 45 mg pioglitazone and metformin (21.3%) at Week 52 (p<0.001).
Alogliptin as add-on therapy to insulin (with or without metformin)
The addition of 25 mg alogliptin once daily to insulin therapy (mean dose = 56.5 IU, with or without metformin) resulted in statistically significant improvements from baseline in HbA1c and fasting
plasma glucose at Week 26 when compared to the addition of placebo (Table 3). Clinically meaningful
reductions in HbA1c compared to placebo were also observed with 25 mg alogliptin regardless of whether patients were receiving concomitant metformin therapy. More patients receiving 25 mg
alogliptin (7.8%) achieved target HbA1c levels of ≤ 7.0% compared to those receiving placebo (0.8%)
at Week 26.

Patients with renal impairment
The efficacy and safety of the recommended doses of alogliptin were investigated separately in a subgroup of patients with type 2 diabetes mellitus and severe renal impairment/end-stage renal disease
in a placebo-controlled study (59 patients on alogliptin and 56 patients on placebo for 6 months) and
found to be consistent with the profile obtained in patients with normal renal function.
Elderly (≥ 65 years old)
The efficacy of alogliptin in patients with type 2 diabetes mellitus and ≥ 65 years old across a pooled analysis of five 26-week placebo-controlled studies was consistent with that in patients < 65 years old.
In addition, treatment with 25 mg alogliptin once daily resulted in improvements from baseline in HbA1c at Week 52 that were similar to those produced by glipizide (mean dose = 5.4 mg). Importantly, despite alogliptin and glipizide having similar HbA1c and fasting plasma glucose changes from baseline, episodes of hypoglycaemia were notably less frequent in patients receiving
25 mg alogliptin (5.4%) compared to those receiving glipizide (26.0%).

Clinical safety
Cardiovascular Safety
In a pooled analysis of the data from 13 studies, the overall incidences of cardiovascular death, non fatal myocardial infarction and non-fatal stroke were comparable in patients treated with 25 mg alogliptin, active control or placebo.
In addition, a prospective randomized cardiovascular outcomes safety study was conducted with
5,380 patients with high underlying cardiovascular risk to examine the effect of alogliptin compared with placebo (when added to standard of care) on major adverse cardiovascular events (MACE)
including time to the first occurrence of any event in the composite of cardiovascular death, nonfatal
myocardial infarction and nonfatal stroke in patients with a recent (15 to 90 days) acute coronary event. At baseline, patients had a mean age of 61 years, mean duration of diabetes of 9.2 years, and
mean HbA1c of 8.0%.
The study demonstrated that alogliptin did not increase the risk of having a MACE compared to placebo [Hazard Ratio: 0.96; 1-sided 99% Confidence Interval: 0-1.16]. In the alogliptin group, 11.3% of patients experienced a MACE compared to 11.8% of patients in the placebo group.

There were 703 patients who experienced an event within the secondary MACE composite endpoint (first event of cardiovascular death, nonfatal myocardial infarction, nonfatal stroke and urgent revascularization due to unstable angina). In the alogliptin group, 12.7% (344 subjects) experienced an event within the secondary MACE composite endpoint, compared with 13.4% (359 subjects) in the placebo group [Hazard Ratio = 0.95; 1-sided 99% Confidence Interval: 0-1.14].
Hypoglycaemia
In a pooled analysis of the data from 12 studies, the overall incidence of any episode of hypoglycaemia was lower in patients treated with 25 mg alogliptin than in patients treated with
12.5 mg alogliptin, active control or placebo (3.6%, 4.6%, 12.9% and 6.2%, respectively). The
majority of these episodes were mild to moderate in intensity. The overall incidence of episodes of severe hypoglycaemia was comparable in patients treated with 25 mg alogliptin or 12.5 mg alogliptin,
and lower than the incidence in patients treated with active control or placebo (0.1%, 0.1%, 0.4% and
0.4%, respectively). In the prospective randomized controlled cardiovascular outcomes study, investigator reported events of hypoglycemia were similar in patients receiving placebo (6.5%) and patients receiving alogliptin (6.7%) in addition to standard of care.
In a clinical trial of alogliptin as mono-therapy, the incidence of hypoglycaemia was similar to that of placebo, and lower than placebo in another trial as add-on to a sulphonylurea.

Higher rates of hypoglycaemia were observed with triple therapy with thiazolidinedione and metformin and in combination with insulin, as observed with other DPP-4 inhibitors.
Patients (≥ 65 years old) with type 2 diabetes mellitus are considered more susceptible to episodes of hypoglycaemia than patients < 65 years old. In a pooled analysis of the data from 12 studies, the overall incidence of any episode of hypoglycaemia was similar in patients ≥ 65 years old treated with
25 mg alogliptin (3.8%) to that in patients < 65 years old (3.6%).
Paediatric population
The European Medicines Agency has deferred the obligation to submit the results of studies with Zytero in one or more subsets of the paediatric population in the treatment of type 2 diabetes mellitus (see section 4.2 for information on paediatric use).

The pharmacokinetics of alogliptin has been shown to be similar in healthy subjects and in patients with type 2 diabetes mellitus.
Absorption
The absolute bioavailability of alogliptin is approximately 100%.
Administration with a high-fat meal resulted in no change in total and peak exposure to alogliptin. Zytero may, therefore, be administered with or without food.
After administration of single, oral doses of up to 800 mg in healthy subjects, alogliptin was rapidly absorbed with peak plasma concentrations occurring 1 to 2 hours (median T max ) after dosing.
No clinically relevant accumulation after multiple dosing was observed in either healthy subjects or in patients with type 2 diabetes mellitus.
Total and peak exposure to alogliptin increased proportionately across single doses of 6.25 mg up to
100 mg alogliptin (covering the therapeutic dose range). The inter-subject coefficient of variation for alogliptin AUC was small (17%).
Distribution
Following a single intravenous dose of 12.5 mg alogliptin to healthy subjects, the volume of distribution during the terminal phase was 417 L indicating that the drug is well distributed into tissues.

Alogliptin is 20-30% bound to plasma proteins.
Biotransformation
Alogliptin does not undergo extensive metabolism, 60-70% of the dose is excreted as unchanged drug in the urine.
Two minor metabolites were detected following administration of an oral dose of [14C] alogliptin, N-demethylated alogliptin, M-I (< 1% of the parent compound), and N-acetylated alogliptin, M-II (< 6% of the parent compound). M-I is an active metabolite and is a highly selective inhibitor of DPP-4 similar to alogliptin; M-II does not display any inhibitory activity towards DPP-4 or other DPP-related enzymes. In vitro data indicate that CYP2D6 and CYP3A4 contribute to the limited metabolism of alogliptin.

In vitro studies indicate that alogliptin does not induce CYP1A2, CYP2B6 and CYP2C9 and does not inhibit CYP1A2, CYP2B6, CYP2C8, CYP2C9, CYP2C19, CYP2D6 or CYP3A4 at concentrations achieved with the recommended dose of 25 mg alogliptin. Studies in vitro have shown alogliptin to be a mild inducer of CYP3A4, but alogliptin has not been shown to induce CYP3A4 in studies in vivo.
In studies in vitro, alogliptin was not an inhibitor of the following renal transporters; OAT1, OAT3 and OCT2.
Alogliptin exists predominantly as the (R)-enantiomer (> 99%) and undergoes little or no chiral conversion in vivo to the (S)-enantiomer. The (S)-enantiomer is not detectable at therapeutic doses.
Elimination
Alogliptin was eliminated with a mean terminal half-life (T 1/2 ) of approximately 21 hours.
Following administration of an oral dose of [14C] alogliptin, 76% of total radioactivity was eliminated in the urine and 13% was recovered in the faeces.
The average renal clearance of alogliptin (170 mL/min) was greater than the average estimated glomerular filtration rate (approx. 120 mL/min), suggesting some active renal excretion.
Time-dependency

Total exposure (AUC(0-inf) ) to alogliptin following administration of a single dose was similar to exposure during one dose interval (AUC(0-24) ) after 6 days of once daily dosing. This indicates no time-dependency in the kinetics of alogliptin after multiple dosing.
Special populations
Renal impairment
A single-dose of 50 mg alogliptin was administered to 4 groups of patients with varying degrees of renal impairment (creatinine clearance (CrCl) using the Cockcroft-Gault formula):
mild (CrCl = > 50 to ≤ 80 mL/min), moderate (CrCl = ≥ 30 to ≤ 50 mL/min), severe (CrCl = < 30 mL/min) and end-stage renal disease on haemodialysis.
An approximate 1.7-fold increase in AUC for alogliptin was observed in patients with mild renal impairment. However, as the distribution of AUC values for alogliptin in these patients was within the same range as control subjects, no dose adjustment for patients with mild renal impairment is necessary (see section 4.2).
In patients with moderate or severe renal impairment, or end-stage renal disease on haemodialysis, an increase in systemic exposure to alogliptin of approximately 2- and 4-fold was observed, respectively. (Patients with end-stage renal disease underwent haemodialysis immediately after alogliptin dosing. Based on mean dialysate concentrations, approximately 7% of the drug was removed during a 3-hour haemodialysis session.) Therefore, in order to maintain systemic exposures to alogliptin that are similar to those observed in patients with normal renal function, lower doses of alogliptin should be used in patients with moderate or severe renal impairment, or end-stage renal disease requiring
dialysis (see section 4.2).
Hepatic impairment
Total exposure to alogliptin was approximately 10% lower and peak exposure was approximately
8% lower in patients with moderate hepatic impairment compared to healthy control subjects. The magnitude of these reductions was not considered to be clinically relevant. Therefore, no dose adjustment is necessary for patients with mild to moderate hepatic impairment (Child-Pugh scores of 5 to 9). Alogliptin has not been studied in patients with severe hepatic impairment (Child-Pugh score > 9, see section 4.2).

Age, gender, race, body weight
Age (65-81 years old), gender, race (white, black and Asian) and body weight did not have any clinically relevant effect on the pharmacokinetics of alogliptin. No dose adjustment is necessary (see section 4.2).
Paediatric population
The pharmacokinetics of alogliptin in children and adolescents < 18 years old has not been established. No data are available (see section 4.2).

Nonclinical data reveal no special hazard for humans based on conventional studies of safety pharmacology and toxicology.
The no-observed-adverse-effect level (NOAEL) in the repeated dose toxicity studies in rats and dogs up to 26 and 39 weeks in duration, respectively, produced exposure margins that were approximately
147- and 227-fold, respectively, the exposure in humans at the recommended dose of 25 mg alogliptin.
Alogliptin was not genotoxic in a standard battery of in vitro and in vivo genotoxicity studies. Alogliptin was not carcinogenic in 2-year carcinogenicity studies conducted in rats and mice. Minimal
to mild simple transitional cell hyperplasia was seen in the urinary bladder of male rats at the lowest dose used (27 times the human exposure) without establishment of a clear NOEL (no observed effect
level).
No adverse effects of alogliptin were observed upon fertility, reproductive performance, or early embryonic development in rats up to a systemic exposure far above the human exposure at the recommended dose. Although fertility was not affected, a slight, statistical increase in the number of abnormal sperm was observed in males at an exposure far above the human exposure at the recommended dose.
Placental transfer of alogliptin occurs in rats.

Alogliptin was not teratogenic in rats or rabbits with a systemic exposure at the NOAELs far above the human exposure at the recommended dose. Higher doses of alogliptin were not teratogenic but
resulted in maternal toxicity, and were associated with delayed and/or lack of ossification of bones and decreased foetal body weights.
In a pre- and postnatal development study in rats, exposures far above the human exposure at the recommended dose did not harm the developing embryo or affect offspring growth and development. Higher doses of alogliptin decreased offspring body weight and exerted some developmental effects considered secondary to the low body weight.
Studies in lactating rats indicate that alogliptin is excreted in milk.
No alogliptin-related effects were observed in juvenile rats following repeat-dose administration for
4 and 8 weeks.

Mannitol
Microcrystalline cellulose
17
Hydroxypropyl cellulose Croscarmellose sodium Magnesium stearate
In addition, the film-coating contains the following inactive ingredients: hypromellose, titanium dioxide, ferric oxide (yellow) and polyethylene glycol and is marked with gray F1 printing ink.

Not applicable.

Do not store above 30 °C.

Primary Packaging Material: The packaging configuration for blister packs is constructed of aluminum forming material and aluminum lidding material.
Secondary Packaging Material: Carton.
Pack sizes of 10, 14, 28, 30, 56, 60, 84, 90, 98 or 100 film-coated tablets. Not all pack sizes may be marketed.

Any unused medicinal product or waste material should be disposed of in accordance with local requirements.